APPLICATION FOR CONSENT
IMPORTANT NOTE TO APPLICANTS
 The April 2016 - April 2017 fee for an application is set by County Council and changes
from time to time. The current fee for consent is $830 for planning review; an additional fee
of $210 is required on County Roads. These fees must be paid before the application is
accepted. An additional fee of $210 will be required before stamping deeds. All cheques
are payable to the UNITED COUNTIES OF STORMONT, DUNDAS & GLENGARRY. If you
have any questions, please contact us at (613) 932-1515, ext. 218.
 The Conservation Authority review fees must be paid prior to circulation, if
applicable. This payment will only be accepted by cheque. Please bring a blank cheque or
call the Administrative-Assistant Planning in advance to confirm the required fee.
 Applications must be reviewed with the local Municipal planning staff in a pre-consultation
meeting. The application will not be accepted without a staff signature. If an application
proposes direct private access onto a County Road, we strongly recommend that the
applicant apply for pre-severance comments from the County Engineer before submitting
the application.
 One application form, sketch, and fee is required for each new parcel being created. (e.g.,
one application will create ONE SEVERED LOT and ONE RETAINED LOT only.)
 Application forms must be typewritten or clearly printed in ink and all questions must be
completed. If the mandatory information is not provided, the approval authority may refuse
to accept or to further consider the application. If incorrect information is provided the
application may not be approved. Each application must be accompanied by a sketch
showing all data listed in question 27 of the application form.
 A poster will be mailed to the individual indicated on Page 1 of the application once the
application has been accepted. This poster is TO BE POSTED IMMEDIATELY and is TO
REMAIN UNTIL THE DECISION OF THE MANAGER OF PLANNING BECOMES FINAL
AND BINDING. The sign should be posted on the severed parcel and must be visible from
a public road. If there is no road frontage on the severed parcel, post the sign on the
retained frontage.
 Your application will be circulated to a number of agencies for comments. These comments
will be considered by the Manager of Planning when evaluating your application. You
should discuss your intentions with these agencies prior to submitting a formal application.
A list of agencies will be provided on request.
 An application for consent must meet policies and requirements of the current municipal
Official Plan, Zoning By-law and the Provincial Policy Statement, prior to approval by the
Manager of Planning.
 The following may result in the application being deferred:
o outstanding reports from the commenting agencies;
o requirement to obtain a legal interpretation;
o failure to post the poster notification as required;
o requirement to obtain additional information with regard to the application; and
o to allow for certain matters to be resolved.

A deposited Reference Plan (survey), and digital copy of the deposited Plan (PDF, TIF, or
DWG), must be provided to the Administrative Assistant-Planning to issue final consent. In
some cases a registerable description can be used instead of a survey, provided it was
approved by the local Registrar with the appropriate stamp and signature on the schedule
page to be stamped by the Administrative Assistant-Planning.
DEPARTMENT OF TRANSPORTATION
AND PLANNING SERVICES
26 Pitt Street, Suite 223, Cornwall, Ontario K6J 3P2
Tel: 613-932-1515 • Fax: 613-936-2913 • Email [email protected] •www.sdgcounties.ca
Application for Consent
Under Section 53 of the Planning Act
Ontario Regulation 197/96
All questions must be completed, in ink or typewritten, or the application will be deemed
incomplete and will not be accepted. Please print clearly.
No. B-
Applicants must pre-consult with the Municipality; the signature below does not imply
Municipal support or approval for the application
*I am satisfied that this application has been accurately completed: ________________________
Municipal Planning Staff
1. Registered Owner(s):
Address:
Postal Code:
Email: ___________________________________ Primary form of contact?
Telephone:
Home:
Bus:
__ Yes __ No
Fax:
Name of Applicant(s) (if different from above):
Address:
Postal Code:
Email: ___________________________________
Telephone:
Home:
Bus:
Fax:
Owner(s) Authorized Agent (if applicable):
Email: ___________________________________
Address:
Telephone:
Postal Code:
Home:
Bus:
Fax:
Please specify the person to be contacted if more information is required. All communications,
including the poster, will be directed to this person:
Registered Owner(s)
□
Applicant(s)
□
Authorized Agent
□
Is the Registered Owner, Applicant or Authorized Agent applying for additional consents
simultaneously with this application? Yes
□
No
□
IMPORTANT: The owner’s authorization, page 7 of 9 of this application form, is required if the
application is submitted by a person, or persons, other than the registered owner(s).
Page 1 of 9
2. (a) Type and purpose of proposed transaction: (please check appropriate box)
TRANSFER:
□ Creation of New Lot
□ Addition to a Lot
□ Easement/Right-of-way
□ Other (Explain):
OTHER:
□ Charge/Mortgage
□ Lease
□ Correction of Title
(b) IF KNOWN, the name of the person(s) to whom the land, or an interest in the land, is
to be transferred, charged or leased:
3. Location of subject land(s): Municipality:
Geographic Township/Village:
Concession Number(s):
Lot Number(s):
Registered Plan No.:
Lot(s)/Block(s):
Reference Plan No.:
Part Number(s):
Name of Street or Road:
Are there any easements or restrictive covenants affecting the subject land?
Yes
□
No
□
If yes, describe the easements or covenant and its effect:
4. Description of lot to be severed:
Frontage:
Depth:
Existing Use:
Area:
Proposed Use:
Number/Use of Existing Buildings/Structure:
Proposed Use for Severed Lot:
5. Description of lot to be retained:
Frontage:
Depth:
Existing Use:
Area:
Proposed Use:
Number/Use of Existing Buildings/Structure:
Page 2 of 9
6. Type of access: (Check appropriate space)
Severed Lot
□
□
□
□
□
□
□
□
Provincial Highway
County Road
Municipal Road (maintained year round)
Municipal Road (seasonally maintained)
Private Road
Right-of-way/Easement
Water Access (specify parking/docking facilities)
Other (specify)
7. Type of water supply proposed or existing?
(check appropriate space)
Retained Lot
□
□
□
□
□
□
□
□
Severed Lot
Proposed Existing
Municipally owned/operated piped water system
Privately owned and operated individual well
Privately owned and operated communal well
Lake or other water body
Not required
Other (specify)
□
□
□
□
□
□
□
□
□
□
□
□
Retained Lot
Proposed Existing
□
□
□
□
□
□
□
□
□
□
□
□
If Proposed, when will services be available?
8. Type of sewage disposal system proposed or existing? Severed Lot
Retained Lot
(check appropriate space)
Proposed Existing Proposed Existing
Municipally owned/operated sanitary sewers
Privately owned/operated individual septic system
Privately owned/operated communal septic system
Pit Privy
Not required
Other (specify)
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
If proposed, when will services be available?
Page 3 of 9
9. What is the existing Official Plan designation(s) of the subject land?
Designation:
If this application relates directly to an Official Plan amendment(s) currently under
review by an approval authority, please indicate the amendment number and the
applicable file number(s):
Amendment number(s):
File number(s):
10. All lands are covered by a Zoning By-law; indicate what the Zoning is for the subject
lands:
Is the area under discussion the subject of an application for a Zoning By-law
Amendment, Minor Variance or approval of a Plan of Submission?
Yes
□
No
If YES, specify the file number and status:
□
□
Unknown
File Number:
Status:
11. Is there an agricultural operation, (INCLUDING, an abattoir, livestock or stock-yard)
within 500 meters?
Yes
□
No
□
Yes
□
No
□
Type of Operation:
12. Is there a landfill within 500 meters?
13. Is there a sewage treatment plant or waste stabilization plant within 500 meters?
Yes
□
□
No
14. Is there a Provincially and/or locally significant wetland (e.g., swamp, bog, etc.) located
on the lands to be severed or retained or within 120 meters?
Yes
□
□
No
15. Is any portion of the land to be severed or retained located within a flood plain?
Yes
□
No
□
No
□
16. Is there a Provincial Park or Crown Lands located within 500 meters?
Yes
□
Page 4 of 9
17. Is there an active, or inactive, mineral extraction site (Pit and/or Quarry) within 500
meters?
Yes
□
□
No
18. Is there an active principal, or secondary, main line Railway within 500 meters?
Yes
19. Is there an Airport or Aircraft landing strip nearby?
Yes
If yes, specify the type:
Federal
□
Provincial
□
□
□
Local
No
□
No
□
□
Distance to your holdings:
20. Is the property within a Municipal drinking water Vulnerable Area as defined in the
Clean Water Act?
Yes
□
No
□
No
□
21. Does this application conform to the 2014 Provincial Policy Statement?
Yes
□
ADDITIONAL INFORMATION:
The following information will assist the Planning office and commenting agencies to
review this Application and MUST BE completed.
22. Is there a noxious Industrial use within 500 meters?
Yes
 Have there been any industrial use/uses on the site?
□
No
□
□
No
□
□
No
□
Yes
 If YES, what was the nature and type of industrial use(s)?
 Have there been commercial use/uses on the site?
Yes
 If YES, what was the nature and type of industrial use(s)?
 Other than for septic systems or landscaping, has fill been brought to, and used,
on the site?
Yes
□
No
□
 Have there been commercial petroleum or other fuel storage on the site,
underground fuel storage, or has the site been used for a gas station at any time?
Yes
 If YES, specify the use and type of fuel(s):
□
No
□
Page 5 of 9
 Is there any reason to believe that the site may have been contaminated by former
uses(s) on the site or adjacent site(s)?
Yes
□
No
□
Unsure
□
 Where did you obtain the information to determine the answers to this section?
(e.g., consultation with the municipality, registry office, previous owners, etc.)
23. Is this a re-submission of a previous application?
Yes
If YES, is the application:
Identical
□
□
No
Changed
□
□
Previous Application for Consent file number:
24. Has the present owner previously severed any land from this holding?
Yes
□
No
□
If YES, provide previous severances on the sketch and give the following information
for each lot severed:
Grantee’s Name:
Date Parcel Created:
Use of Parcel:
File Number (if known)
25. Has the subject land ever been, or is it now, the subject of an application for a Plan of
Subdivision under Section 51 of the Planning Act, or its predecessors?
Yes
If YES, provide the following information:
□
No
□
File Number Date of Final Approval -
26. OTHER INFORMATION:
 An explanation as to the reason and purpose for this severance must be provided
or the application will be deemed to be incomplete.
Explanation for Severance:
Page 6 of 9
27. REQUIRED SKETCH – The application must be accompanied by a sketch showing the
following:
 the boundaries and dimensions of the subject land (subject land means the part that is to
be severed and the part that is to be retained);
 the boundaries and dimensions of any land abutting the subject land that is owned by the
owner of the subject land;
 the distance between the subject land and the nearest township lot line or landmark, such
as a railway crossing or bridge;
 the location of all land previously severed from the parcel originally acquired by the
current owner of the subject land;
 the approximate location of all natural and artificial features on the subject land, and
adjacent land, that in the opinion of the applicant may affect the application, such as
buildings, railways, roads, watercourses, drainage ditches, river or stream banks,
wetlands, wooded areas, barns, wells and septic systems;
 the location, width and name of any roads within, or abutting, the subject land, indicating
whether it is a Provincial highway, County Road, an unopened road allowance, a public
traveled road, a private road or a right-of-way;
 if access to the subject land is by water only, the approximate distance of the parking and
docking facilities from the subject land and the nearest public road; and
 the location and nature of any easement affecting the subject land.
 “SUBJECT LAND” means the land to be SEVERED and the land to be RETAINED
28. AUTHORIZATION: If the applicant is not the owner of the land that is the subject of this
application, the written authorization of the owner that the applicant is authorized to
make this application on their behalf must be included with this form or alternatively
the authorization, as set out below, must be completed by the Registered Owner(s):
I/We,
, being the Registered
Owner(s) of the land(s) that are the subject of this Application for Consent,
hereby authorize
, to prepare and
submit this application on my/our behalf.
Date
Signature of Registered Owner(s)
Signature of Registered Owner(s)
Page 7 of 9
29. AFFIDAVIT/SWORN DECLARATION: This must be completed by the Applicant(s) for
the proposed consent:
DECLARATION
I/We
, of the
Name of the Registered Owner(s)/Applicant/Authorized Agent
, in the
(name of City, Town, Township, etc.)
(County, Region, District, Municipality)
do solemnly declare that all the statements contained in this Application for Consent
for
,
(Property Description)
and all supporting documents are true, and I/We make this solemn declaration
conscientiously believing it to be true and complete, and knowing that it is of the
same force and effect as if made under oath, by virtue of the “Canada Evidence Act”.
Sworn (or Declared) before me:
at the,
(signature Registered Owner(s)/Applicant/Authorized Agent)
in the,
(signature Registered Owner(s)/Applicant/Authorized Agent)
this
day of
,
A Commissioner of Oaths
30. PERMISSION TO ACCESS PROPERTY
I hereby authorize and consent to permit municipal and Conservation Authority staff
to enter upon the subject property during regular business hours during the time
that the application is under consideration by the Counties of Stormont, Dundas and
Glengarry for the purpose of conducting site inspections.
______________________________________
Owner(s)/Applicant/Authorized Agent Signature
_________________
Date
Accepted by the Administrative Assistant-Planning on the following date:
Application for Consent - File Number:
BPage 8 of 9
Page 9 of 9